PRACTICE CHANGER
To shorten recovery time for adults with acute cervical radiculopathy, recommend either physical therapy (PT) and a home exercise plan or a cervical collar and rest.1 Both are more effective than a wait-and-see strategy.1
STRENGTH OF RECOMMENDATION
B: Based on a single well-done randomized controlled trial (RCT).
Kuijper B, Tans JT, Beelen A, et al. Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomized trial. BMJ. 2009;339:b3883.
Illustrative case
James M, a 43-year-old self-employed mechanic, came to see you 2 weeks ago because of neck pain radiating to his right shoulder, arm, forearm, and dorsum of his hand. You diagnosed acute right-sided cervical radiculopathy and prescribed a nonsteroidal anti-inflammatory drug.
Today he’s back in your office, reporting that he has experienced only minimal transient relief. You reassure him that the pain will subside within a few months, but james wants to know if you can give him something to speed up his recovery and enable him to return to work.
Each year in the United States, approximately 85 out of every 100,000 adults develop cervical radiculopathy2—a neurologic condition characterized by dysfunction of a cervical spinal nerve, the roots of the nerve, or both. In addition to pain in the neck and the arm on the affected side, patients often develop sensory loss, loss of motor function, and/or reflex changes in the affected nerve-root distribution.
Most patients respond to conservative measures
A nonsurgical approach is the preferred first-line treatment strategy for cervical radiculopathy.3 The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders—an international network of experts in a number of specialties—found no evidence that surgery provides better long-term outcomes than more conservative treatment.3 Approximately 80% to 90% of patients respond to a conservative approach, with improvements in pain, function, and mood in 3 to 6 months.4,5
There are numerous conservative therapies for cervical radiculopathy, including oral analgesics, rest, cervical traction, short-term immobilization with a cervical collar, PT, a short course of oral corticosteroids, and perineural steroid injections.4-6 These therapies may be used singly or in combination. Until now, however, no high-quality RCTs compared the efficacy of various nonsurgical treatment modalities for acute cervical radiculopathy—and their effectiveness is still subject to debate.
STUDY SUMMARY: Initially, both Tx modes beat wait-and-see
The study by Kuijper et al1 is the first RCT to compare the effectiveness of PT, cervical collars, and a wait-and-see strategy in alleviating symptoms of cervical radiculopathy. Enrollees (N=205) were men and women ages 18 to 75 years who were referred by general practitioners in 3 Dutch hospitals. All the participants had a diagnosis of cervical radiculopathy confirmed by a neurologist. In addition, all the cases were of recent onset, with symptoms of <1 month’s duration at the time of enrollment. Patients with clinical signs of cord compression and those who had previously been treated with either PT or a cervical collar for this episode were excluded.
The researchers randomized the participants into 3 groups: PT, cervical collar, or control. All the groups were comparable at baseline.
Those in the PT group received twice weekly therapy for 6 weeks, with a focus on mobilizing and stabilizing the cervical spine. They were also taught to perform home exercises and advised to do the exercises daily.
Patients in the cervical collar group were given a semi-hard, snugly fitted collar and instructed to wear it during the day for 3 weeks—and to rest as much as possible. They were weaned from the collar over the course of another 3 weeks.
Participants in the control group were simply told to follow their normal daily routine as much as possible. All 3 groups were permitted to take oral pain medication as needed.
The primary outcome measures were changes over time in neck and arm pain scores, using 2 validated measurement tools: a 100-mm visual analog scale (VAS) and a 100-point neck disability index (NDI). Both tools were used at 3 weeks, 6 weeks, and 6 months. Secondary outcomes were treatment satisfaction (as measured on a 5-point scale), use of opiates, and working status.